Venous sinus thrombosis during COVID-19 infection in pregnancy: a case report

ABSTRACT BACKGROUND: Although it is known that the new coronavirus disease (COVID-19), which was first seen in Wuhan, China, in December 2019 and has affected the whole world, mainly targets the respiratory tract, cases of this disease with a wide clinical spectrum are emerging as information is shared. CASE REPORT: We present the case of a pregnant woman who was diagnosed with venous sinus thrombosis after she developed headache and hemiparesis. Polymerase chain reaction (PCR) positivity lasted for two weeks after COVID-19 had been diagnosed. CONCLUSIONS: In patients with suspected COVID-19, especially in the presence of causes of hypercoagu- lability and presence of atypical features, venous sinus thrombosis needs to be kept in mind in making the differential diagnosis.

and lower left extremities. The foot sole skin reflex of the right lower extremity consisted of an extensor response. She presented decreased speech fluency and had difficulty in word finding, which were diagnosed as mild motor aphasia. Laboratory tests revealed high levels of fibrinogen (899 g/l; normal is 180-400) and D-dimer (6.38 mg/l; normal is 0-2). It was noted that the patient had also had high levels of fibrinogen (665 g/l) and D-dimer (2.2 mg/l) in examinations performed 10 days previously.
Diffusion magnetic resonance imaging (MRI) showed cortical diffusion restriction in the left parietal region (Figure 1a) and a hypointense response in the apparent diffusion coefficient (ADC) (Figure 1b). The result from the diffusion MRI was suggestive of venous sinus thrombosis. Widespread loss of flow in the superior sagittal sinus and right transverse sinus, suggesting partial venous thrombosis in the left transverse sinus, was observed in brain magnetic resonance imaging (Figure 2a) and   Figure   3). There was an increase in infection parameters, and the patient was started on hydroxychloroquine and ceftriaxone treatment.
In the examinations performed to ascertain risk factors, the patient was found to be positive for antinuclear antibodies (ANA) and showed prothrombin heterozygous mutation. The patient was negative for anti-cardiolipin antibodies and anti-double stranded DNA (dsDNA), and tests on lupus anticoagulant, homocysteine, protein C, protein S and antithrombin 3 showed results within normal limits. On the third day following the birth, the patient's headache complaint became completely resolved, her thrombocyte counts stopped decreasing and her thrombocytopenia improved over the subsequent days. The infection parameters regressed. Partial regression of the lesions was observed on control thoracic computed tomography. The patient's general condition stabilized and she was discharged on the 10th day of hospitalization, with muscle strength 4-5/5 on the right side, which was mobilized without support. Continuation of low molecular weight heparin (LMWH) treatment was planned, along with neurological and hematological control tests at a polyclinic.

It is known that the new coronavirus disease (COVID-19),
which was first seen in Wuhan, China, in December 2019 and has affected the whole world, mainly targets the respiratory tract.
Cases of this disease with a wide clinical spectrum are emerging as information is shared.
Although the mechanism for thrombotic events in the course of COVID-19 remains unclear, it is known that there is a tendency for such events to occur within the course of this disease.
Pulmonary embolism was shown to be the cause of death in an autopsy series. 6 The etiology of embolic events is generally multifactorial: it is accepted that these events are triggered by environ- ischemic and one of them presented hemorrhagic cerebrovascular disease (0.5%), after an average of 10 days after the onset of COVID-19. They pointed out that the mean age of these patients was greater and their cardiovascular and cerebrovascular risk factors were more severe. 11 COVID-19 is thought to predispose patients to thrombotic pathological conditions in both venous and arterial circulation due to inflammation, platelet activation, endothelial dysfunction and stasis. 4 The initial signs of coagulopathy due to  have been found to be marked increases in fibrin/fibrinogen-degradation products and D-dimer levels. It was observed that our patient had high levels of fibrinogen and D-dimer from the time when she was diagnosed with COVID-19 to the time when she was diagnosed with venous sinus thrombosis.
In the early stages of the disease, abnormalities in prothrom- The primary treatment for venous sinus thrombosis is anticoagulation, based on the limited evidence from randomized trials.
Although a small series of cases has indicated that endovascular therapy may be promising, these data require confirmation through a randomized trial. Decompressive surgery can be lifesaving for patients at risk of herniation. The prognosis is generally better than that for arterial stroke. 12 Although venous sinus thrombosis was previously considered to be a life-threatening condition, it is known that the mortality rate in these cases declines over time.
Moreover, increased clinical awareness, development of neuroimaging techniques and improvement in therapeutic management have provided better prognoses through enabling earlier diagnosis and identification of less severe cases. 13 Pregnancy and the puerperium are common causes of transient prothrombotic conditions. About 2% of pregnancy-related strokes can be attributed to venous sinus thrombosis. In the puerperium, the rate of venous sinus thrombosis is 12 cases per 100,000 births. This venous rate in the puerperal period is only slightly lower than that of arterial stroke. Women are at risk of venous thromboembolic events during pregnancy and for up to six to eight weeks after delivery. Most cases of pregnancy-related venous sinus thrombosis are seen in the third trimester or, more often, in the puerperium, when the body prepares for delivery through hypercoagulation. In a paper published in Canada, it was reported that frequency of venous sinus thrombosis in the postpartum period is much higher than during pregnancy. In the puerperium period, the presence of infection and use of instrumental delivery or cesarean section increase the risk of venous sinus thrombosis. During pregnancy, it is known that the risk of venous sinus thrombosis increases in the presence of hypertension, infections and excessive vomiting, and as the maternal age increases. 14 The European Academy of Neurology has recommended that treatment for acute venous sinus thrombosis should start with oral anticoagulant therapy (vitamin K antagonists) for 3-12 months, according to risk factors. 15 Another risk factor with a relationship to venous sinus thrombosis that is clearly known is inflammation. Venous sinus thrombosis is associated with systemic inflammatory conditions such as Behçet's disease and inflammatory bowel disease, in addition to infections such as otitis, mastoiditis, sinusitis, dental infections and skin abscesses in neighboring tissues and meningitis. 13 In the anamnesis and examination of our patient, no finding suggesting adjacent tissue infection or Behçet's or inflammatory bowel disease was found.
Antinuclear antibody positivity can be seen in autoimmune diseases, especially systemic lupus erythematosus, but it is not a laboratory test specific to autoimmune diseases. Since antinuclear antibody positivity can be observed in acute or chronic infectious processes, 16 it was planned that our patient would undergo this Reports correlating COVID-19, headache and pregnancy are very rare ( Table 1).

CONCLUSION
Headache is one of the common symptoms of COVID-19. In the presence of other risk factors accompanying COVID-19, the risk of thromboembolic events increases significantly. Among patients with suspected COVID-19, considering venous sinus thrombosis in the differential diagnosis may be life-saving, through enabling early diagnosis and treatment. This is especially so in the presence of causes of hypercoagulability such as pregnancy, malignancy and presence of atypical features like analgesic unresponsiveness, awakening from sleep, visual impairment, neurological deficits or seizures.